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Saro R, Allegro V, Merlo M, Dore F, Sinagra G, Porcari A. Specific Therapy in Transthyretin Amyloid Cardiomyopathy: Future Perspectives Beyond Tafamidis. Heart Fail Clin 2024; 20:343-352. [PMID: 38844305 DOI: 10.1016/j.hfc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a relatively prevalent cause of morbidity and mortality. Over the recent years, development of disease-modifying treatments has enabled stabilization of the circulating transthyretin tetramer and suppression of its hepatic production, resulting in a remarkable improvement in survival of patients with ATTR-CM. Second-generation drugs for silencing are currently under investigation in randomized clinical trials. In vivo gene editing of transthyretin has been achieving unanticipated suppression of hepatic production in ATTR-CM. Trials of antibodies inducing the active removal of transthyretin amyloid deposits in the heart are ongoing, and evidence has gathered for exceptional spontaneous regression of ATTR-CM.
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Affiliation(s)
- Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Valentina Allegro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Franca Dore
- Head of Nuclear Medicine Division, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Aldostefano Porcari
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy; National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK.
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Porcari A, Sinagra G, Gillmore JD, Fontana M, Hawkins PN. Breakthrough advances enhancing care in ATTR amyloid cardiomyopathy. Eur J Intern Med 2024; 123:29-36. [PMID: 38184468 DOI: 10.1016/j.ejim.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) has been traditionally considered a rare and inexorably fatal condition. ATTR-CM now is an increasingly recognized cause of heart failure (HF) and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CM, which is now possible without recourse to endomyocardial biopsy in ≈70 % of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CM and more accurate prognostic stratification. Although radionuclide scintigraphy with 'bone' tracers has an established diagnostic value, the diagnostic performance of the bone tracers validated for non-invasive confirmation of ATTR-CM may not be equal. Characterising the wider clinical phenotype of patients with ATTR-CM has enabled identification of features with potential for earlier diagnosis such as carpal tunnel syndrome. Therapies able to slow or halt ATTR-CM progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional HF medications. Cutting-edge research in the field of antibody-mediated removal of ATTR deposits compellingly suggest that ATTR-CM is a truly reversible disorder, bringing hope for patients even with advanced disease. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK; Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy.
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
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İrgi T, Baycan ÖF, Güvenç TS, Özcan FB, Atıcı A, Yılmaz Y, Çalişkan M. Concomitant amyloidosis is the primary cause of endothelial and coronary microvascular dysfunction in carpal tunnel syndrome. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 41:100393. [PMID: 38655035 PMCID: PMC11035090 DOI: 10.1016/j.ahjo.2024.100393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024]
Abstract
Study objectives Patients with carpal tunnel syndrome (CTS) show manifestations of arterial abnormalities, including carotid intimal thickening and increased vascular stiffness. As carpal tunnel syndrome is associated with amyloidosis, we hypothesized that previously observed abnormalities can largely be related with concomitant amyloidosis rather than CTS itself. Design Prospective observational study. Setting Medeniyet University Goztepe Hospital. Participants 61 patients with CTS (of whom 32 had biopsy-proven amyloidosis) and 36 healthy controls. Interventions Subjects underwent ultrasound examinations for the measurement of coronary flow velocity reserve (CFVR), flow-mediated vasodilatation (FMD) and carotid intimal-media thickness (CIMT). Main outcome measures Comparison of CFVR, FMD and CIMT in CTS patients with or without amyloidosis. Results Patients with either CTS or CTS with concomitant amyloidosis (CTS-A) had significantly lower FMD (9.7 % ± 4.0 % in CTS and 10.3 % ± 4.6 % in CTS-A groups, p < 0.05 for both) and CFVR (2.4 (2.1-2.8) in CTS and 1.8 (1.6-2.1) in CTS-A groups, p < 0.001 for both) as compared to controls, while CIMT was only increased in CTS-A group (0.70 (0.60-0.80), p < 0.001). The reduction in CFVR was solely related to an increased basal flow velocity in CTS patients while there was also a reduced hyperemic flow velocity in patients with CTS-A. Conclusion Most arterial phenomena in CTS patients could be attributable to concomitant amyloidosis, although endothelial dysfunction was present even in patients with CTS without amyloidosis.
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Affiliation(s)
- Tuğçe İrgi
- Istanbul Medeniyet University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Ömer Faruk Baycan
- Istanbul Medeniyet University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Tolga Sinan Güvenç
- Istinye University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Fatma Betül Özcan
- Istanbul Medeniyet University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Adem Atıcı
- Istanbul Medeniyet University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Yusuf Yılmaz
- Istanbul Medeniyet University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Mustafa Çalişkan
- Istanbul Medeniyet University School of Medicine, Department of Cardiology, Istanbul, Turkey
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Shetty NS, Pampana A, Patel N, Maurer MS, Goyal P, Li P, Arora G, Arora P. Carpal Tunnel Syndrome and Transthyretin Amyloidosis in the All of Us Research Program. Mayo Clin Proc 2024:S0025-6196(23)00564-5. [PMID: 38661598 DOI: 10.1016/j.mayocp.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/09/2023] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To evaluate the association of carpal tunnel syndrome (CTS) with incident heart failure and incident amyloidosis and to assess the risk of CTS in pathogenic TTR genetic variant carriers. METHODS This prospective cohort study included multiethnic US adults 18 years of age and older without prevalent heart failure and amyloidosis with available genotypic data from the All of Us Research Program. The primary outcomes were incident heart failure and incident amyloidosis. The association of incident heart failure and incident amyloidosis with CTS was assessed using multivariable adjusted Cox models accounting for age, sex, race and ethnicity, obesity, hypertension, diabetes, statin use, and smoking status. RESULTS Of the 166,987 individuals included, the median age was 54 (38 to 66) years; 105,279 (63.0%) were female, and 92,780 (55.6%) were non-Hispanic White individuals; CTS was identified in 12,407 (7.4%) individuals. Compared with individuals without CTS, the adjusted hazard ratio for incident heart failure was 1.13 (95% CI, 1.02 to 1.26) in individuals with CTS. The risk of amyloidosis was ∼3-fold higher (adjusted hazard ratio, 2.86; 95% CI, 1.71 to 4.77) in individuals with CTS compared with those without CTS. Individuals carrying a pathogenic TTR variant had an approximately 40% higher risk (adjusted hazard ratio, 1.38; 95% CI, 1.16 to 1.65) for development of CTS compared with noncarriers. CONCLUSION Cardiac amyloidosis screening programs may use CTS as a sentinel event and use genetic testing to identify individuals at a higher risk of TTR amyloidosis.
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Affiliation(s)
- Naman S Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Akhil Pampana
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Mathew S Maurer
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, Cornell University, New York, NY
| | - Peng Li
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL; Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL.
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Chaudhary R, Khanna J, Bansal S, Bansal N. Current Insights into Carpal Tunnel Syndrome: Clinical Strategies for Prevention and Treatment. Curr Drug Targets 2024; 25:221-240. [PMID: 38385490 DOI: 10.2174/0113894501280331240213063333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/01/2024] [Accepted: 01/12/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a condition that is caused by medial nerve compression, resulting in symptoms such as numbness, tightness, or weakness in the hand. OBJECTIVES The aim of the study was to find out the genetic modulation, mechanism, available treatment, and recommendation for carpal tunnel syndrome at its specific stage. METHODS Almost 200 papers were searched for this review article, and 145 articles were selected. The literature was collected from different sources like Google scholar, PubMed, a directory of open-access journals, and science.gov by using keywords, such as treatment, risk factors, recommendation, and clinical features of carpal tunnel syndrome. RESULTS The most efficient non-surgical treatment is methylprednisolone acetate, which reduces inflammation by acting on the glucocorticoid receptor in conjunction with immunofilling. It has also been used successfully as a second-line drug for the treatment of patients with mild or moderate conditions in order to provide relief. New non-pharmacological options include laser therapy in acupuncture, transcutaneous electric nerve stimulation (TENS), and sham therapy. Modern treatments like TENS, laser therapy, splints, and injections of methylprednisolone acetate have been demonstrated to be helpful in sporadic situations. For patients with mild and moderate problems, more research should be conducted that includes the combination of these surgical and non-surgical treatments. CONCLUSION We propose a multifunctional panel construct and define standard data items for future research into carpal tunnel syndrome. A discussion on idiopathic carpal tunnel syndrome, risk factors, combination of therapies, using guidelines-based recommendations and treatment should be initiated.
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Affiliation(s)
- Rishabh Chaudhary
- Department of Pharmacology, M. M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana-133207, India
| | - Janvi Khanna
- Department of Pharmacology, M. M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana-133207, India
| | - Seema Bansal
- Department of Pharmacology, M. M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana-133207, India
| | - Nitin Bansal
- Department of Pharmacy, Chaudhary Bansilal University, Bhiwani, India
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Fontana M, Porcari A, Hawkins PN. Standardising Care and Treatment of Transthyretin Amyloid Cardiomyopathy. Glob Heart 2023; 18:63. [PMID: 38028963 PMCID: PMC10668877 DOI: 10.5334/gh.1275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) has been traditionally considered a rare and inexorably fatal condition. ATTR-CA now is an increasingly recognised cause of heart failure and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CA, which is now possible without recourse to endomyocardial biopsy in around 70% of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CA and more accurate prognostic stratification. Therapies able to slow or halt ATTR-CA progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional heart failure medications. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, IT
- European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Europe
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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Porcari A, Sinagra G, Gillmore JD. Editorial: Proceedings and predictions in cardiac amyloidosis: unsolved mysteries and challenges for the future. Front Med (Lausanne) 2023; 10:1232212. [PMID: 37529239 PMCID: PMC10389709 DOI: 10.3389/fmed.2023.1232212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/05/2023] [Indexed: 08/03/2023] Open
Affiliation(s)
- Aldostefano Porcari
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- European Reference Network for RARE, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- European Reference Network for RARE, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Julian D. Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
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Porcari A, Sinagra G, Quarta CC, Fontana M, Gillmore JD. Final farewell to Claudio Rapezzi: observation, deduction and knowledge in medicine. Front Cardiovasc Med 2023; 10:1221983. [PMID: 37378409 PMCID: PMC10291057 DOI: 10.3389/fcvm.2023.1221983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart
| | - Cristina Candida Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
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Abstract
Endomyocardial biopsy (EMB) is an invasive procedure originally developed for the monitoring of heart transplant rejection. Over the year, this procedure has gained a fundamental complementary role in the diagnostic work-up of several cardiac disorders, including cardiomyopathies, myocarditis, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Major advances in EMB equipment and techniques for histological analysis have significantly improved diagnostic accuracy of EMB. In recent years, advanced imaging modalities such as echocardiography with three-dimensional and myocardial strain analysis, cardiac magnetic resonance and bone scintigraphy have transformed the non-invasive approach to diagnosis and prognostic stratification of several cardiac diseases. Therefore, it emerges the need to re-define the current role of EMB for diagnostic work-up and management of cardiovascular diseases. The aim of this review is to summarize current knowledge on EMB in light of the most recent evidences and to discuss current indications, including challenging scenarios encountered in clinical practice.
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Porcari A, Allegro V, Saro R, Varrà GG, Pagura L, Rossi M, Lalario A, Longo F, Korcova R, Dal Ferro M, Perkan A, Dore F, Bussani R, De Sabbata GM, Zaja F, Merlo M, Sinagra G. Evolving trends in epidemiology and natural history of cardiac amyloidosis: 30-year experience from a tertiary referral center for cardiomyopathies. Front Cardiovasc Med 2022; 9:1026440. [PMID: 36419501 PMCID: PMC9677956 DOI: 10.3389/fcvm.2022.1026440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/17/2022] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVE Natural history of cardiac amyloidosis (CA) is poorly understood. We aimed to examine the changing mortality of different types of CA over a 30-year period. PATIENTS AND METHODS Consecutive patients included in the "Trieste CA Registry" from January 1, 1990 through December 31, 2021 were divided into a historical cohort (diagnosed before 2016) and a contemporary cohort (diagnosed after 2016). Light chain (AL), transthyretin (ATTR) and other forms of CA were defined according to international recommendations. The primary and secondary outcome measures were all-cause mortality and cardiac death, respectively. RESULTS We enrolled 182 patients: 47.3% AL-CA, 44.5% ATTR-CA, 8.2% other etiologies. The number of patients diagnosed with AL and ATTR-CA progressively increased over time, mostly ATTR-CA patients (from 21% before 2016 to 67% after 2016) diagnosed non-invasively. The more consistent increase in event-rate was observed in the long-term (after 50 months) in ATTR-CA compared to the early increase in mortality in AL-CA. In the contemporary cohort, during a median follow up of 16 [4-30] months, ATTR-CA was associated with improved overall and cardiac survival compared to AL-CA. At multivariable analysis, ATTR-CA (HR 0.42, p = 0.03), eGFR (HR 0.98, p = 0.033) and ACE-inhibitor therapy (HR 0.24, p < 0.001) predicted overall survival in the contemporary cohort. CONCLUSION Incidence and prevalence rates of ATTR-CA and, to a less extent, of AL-CA have been increasing over time, with significant improvements in 2-year survival of ATTR-CA patients from the contemporary cohort. Reaching an early diagnosis and starting disease-modifying treatments will improve long-term survival in CA.
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Affiliation(s)
- Aldostefano Porcari
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Valentina Allegro
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Riccardo Saro
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Guerino Giuseppe Varrà
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Linda Pagura
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Maddalena Rossi
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Andrea Lalario
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Francesca Longo
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Renata Korcova
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Matteo Dal Ferro
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Andrea Perkan
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Rossana Bussani
- Cardiothoracic Department, Center for Diagnosis and Treatment of Cardiomyopathies, Institute of Pathological Anatomy and Histology, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Trieste, Italy
| | | | - Francesco Zaja
- Department of Hematology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
- Department of Medical Science, University of Trieste, Trieste, Italy
| | - Marco Merlo
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Department of Cardiovascular, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERNGUARD-Heart, University of Trieste, Trieste, Italy
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Ladefoged B, Clemmensen T, Dybro A, Hartig‐Andreasen C, Kirkeby L, Gormsen LC, Bomholt P, Gillmore J, Poulsen SH. Identification of wild-type transthyretin cardiac amyloidosis in patients with carpal tunnel syndrome surgery (CACTuS). ESC Heart Fail 2022; 10:234-244. [PMID: 36193570 PMCID: PMC9871677 DOI: 10.1002/ehf2.14173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/03/2022] [Accepted: 09/15/2022] [Indexed: 01/29/2023] Open
Abstract
AIMS Wild-type transthyretin cardiac amyloidosis (ATTRwt) is an infiltrative cardiomyopathy with a poor prognosis. The condition is associated with carpal tunnel syndrome (CTS), which often precedes the ATTRwt diagnosis by several years. The aim of the study was (i) to screen patients with a recent history of CTS for ATTRwt using red flags, (ii) to determine whether patients with screened ATTRwt had less advanced disease compared with patients with clinical ATTRwt, and (iii) to assess the sensitivity and specificity of known red flags in ATTRwt. METHODS AND RESULTS Patients aged ≥60 years at the time of CTS surgery were invited for screening. Red flags were defined as elevated biomarker levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) or cardiac troponin, an electrocardiogram pattern associated with ATTRwt, left ventricular hypertrophy (LVH), and impaired longitudinal strain with apical sparring. All patients with a red flag were referred for a diagnostic scintigraphy. Patients with ATTRwt diagnosed by screening were compared with patients with clinical ATTRwt (n = 51) matched by age, gender, and CTS surgery. Among the 120 enrolled subjects (mean age 74.5 years, 90% male), the suspicion of ATTR was raised in 67 (55.8%), and 10 (8.3%) were diagnosed with ATTRwt. Patients identified with ATTRwt were predominantly asymptomatic and had mildly elevated NT-proBNP, mildly increased LVH, preserved left ventricular ejection fraction, and systolic longitudinal function, which differed significantly from clinical ATTRwt controls (P < 0.001). CONCLUSIONS The study found an ATTRwt prevalence of 8.3% in a population of age and gender-selected patients with a recent history of CTS. The identified patients with ATTRwt had less structural and functional cardiac involvement than clinical ATTRwt controls.
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Affiliation(s)
- Bertil Ladefoged
- Department of CardiologyAarhus University HospitalPalle Juul‐Jensens Boulevard 998200Aarhus NDenmark
| | - Tor Clemmensen
- Department of CardiologyAarhus University HospitalPalle Juul‐Jensens Boulevard 998200Aarhus NDenmark
| | - Anne Dybro
- Department of CardiologyAarhus University HospitalPalle Juul‐Jensens Boulevard 998200Aarhus NDenmark
| | | | - Lone Kirkeby
- Department of Orthopedic SurgeryRegional Hospital HolstebroHolstebroDenmark
| | | | - Peter Bomholt
- Department of CardiologyAarhus University HospitalPalle Juul‐Jensens Boulevard 998200Aarhus NDenmark
| | - Julian Gillmore
- The National Amyloidosis CentreThe Royal Free HospitalLondonUK
| | - Steen Hvitfeldt Poulsen
- Department of CardiologyAarhus University HospitalPalle Juul‐Jensens Boulevard 998200Aarhus NDenmark
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12
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Porcari A, Fontana M, Gillmore JD. Transthyretin cardiac amyloidosis. Cardiovasc Res 2022; 118:3517-3535. [PMID: 35929637 PMCID: PMC9897687 DOI: 10.1093/cvr/cvac119] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/16/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized cause of heart failure (HF) and mortality worldwide. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have shifted ATTR-CA from a rare and untreatable disease to a relatively prevalent condition that clinicians should consider on a daily basis. Amyloid fibril formation results from age-related failure of homoeostatic mechanisms in wild-type ATTR (ATTRwt) amyloidosis (non-hereditary form) or destabilizing mutations in variant ATTR (ATTRv) amyloidosis (hereditary form). Longitudinal large-scale studies in the United States suggest an incidence of cardiac amyloidosis in the contemporary era of 17 per 100 000, which has increased from a previous estimate of 0.5 per 100 000, which was almost certainly due to misdiagnosis and underestimated. The presence and degree of cardiac involvement is the leading cause of mortality both in ATTRwt and ATTRv amyloidosis, and can be identified in up to 15% of patients hospitalized for HF with preserved ejection fraction. Associated features, such as carpal tunnel syndrome, can preceed by several years the development of symptomatic HF and may serve as early disease markers. Echocardiography and cardiac magnetic resonance raise suspicion of disease and might offer markers of treatment response at a myocardial level, such as extracellular volume quantification. Radionuclide scintigraphy with 'bone' tracers coupled with biochemical tests may differentiate ATTR from light chain amyloidosis. Therapies able to slow or halt ATTR-CA progression and increase survival are now available. In this evolving scenario, early disease recognition is paramount to derive the greatest benefit from treatment.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK,Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Julian D Gillmore
- Corresponding author. Tel: +44 2074332764; fax: +44 2044332817; E-mail:
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13
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Porcari A, Merlo M, Sinagra G. Time to reconsider thromboembolic risk and anticoagulation in transthyretin cardiac amyloidosis? Eur J Heart Fail 2022; 24:1716-1718. [PMID: 35919942 DOI: 10.1002/ejhf.2648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
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14
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Argiro' A, Zampieri M, Mazzoni C, Catalucci T, Biondo B, Tomberli A, Gabriele M, Di Mario C, Perfetto F, Cappelli F. Red flags for the diagnosis of cardiac amyloidosis: simple suggestions to raise suspicion and achieve earlier diagnosis. J Cardiovasc Med (Hagerstown) 2022; 23:493-504. [PMID: 35904994 DOI: 10.2459/jcm.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac amyloidosis is an infiltrative disease characterized by extracellular deposition of insoluble amyloid fibrils in the heart leading to organ dysfunction. Despite recent diagnostic advances, the diagnosis of cardiac amyloidosis is often delayed or even missed. Furthermore, a long diagnostic delay is associated with adverse outcomes, with the early diagnosed patients showing the longest survival. In this narrative review we aimed to summarize the 'red flags' that may facilitate the correct diagnosis. The red flags may be classified as clinical, biohumoral, electrocardiographic, echocardiographic, and cardiac magnetic resonance features and should promptly raise the suspicion of cardiac amyloidosis in order to start a correct diagnostic pathway and targeted treatment strategies that may improve patients' outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlo Di Mario
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre
- IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
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15
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Rossi M, Varrà GG, Porcari A, Saro R, Pagura L, Lalario A, Dore F, Bussani R, Sinagra G, Merlo M. Re-Definition of the Epidemiology of Cardiac Amyloidosis. Biomedicines 2022; 10:biomedicines10071566. [PMID: 35884871 PMCID: PMC9313045 DOI: 10.3390/biomedicines10071566] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/09/2022] [Accepted: 06/20/2022] [Indexed: 11/29/2022] Open
Abstract
The epidemiology of cardiac amyloidosis (CA), traditionally considered a rare and incurable disease, has changed drastically over the last ten years, particularly due to the advances in diagnostic methods and therapeutic options in the field of transthyretin CA (ATTR-CA). On the one hand, the possibility of employing cardiac scintigraphy with bone tracers to diagnose ATTR-CA without a biopsy has unveiled the real prevalence of the disease; on the other, the emergence of effective treatments, such as tafamidis, has rendered an early and accurate diagnosis critical. Interestingly, the following subgroups of patients have been found to have a higher prevalence of CA: elderly subjects > 75 years, patients with cardiac hypertrophy hospitalized for heart failure with preserved ejection fraction, subjects operated on for bilateral carpal tunnel syndrome, patients with cardiac hypertrophy not explained by concomitant factors and individuals with aortic valve stenosis. Many studies investigating the prevalence of CA in these particular populations have contributed to rewriting the epidemiology of the disease, increasing the awareness of the medical community for a previously underappreciated condition. In this review, we summarized the latest evidence on the epidemiology of CA according to the different clinical settings typically associated with the disease.
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Affiliation(s)
- Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Guerino Giuseppe Varrà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Linda Pagura
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Andrea Lalario
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy;
| | - Rossana Bussani
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracic Department, Institute of Pathological Anatomy and Histology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, 34149 Trieste, Italy;
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
- Correspondence:
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16
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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17
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Porcari A, Rossi M, Cappelli F, Canepa M, Musumeci B, Cipriani A, Tini G, Barbati G, Varrà GG, Morelli C, Fumagalli C, Zampieri M, Argirò A, Vianello PF, Sessarego E, Russo D, Sinigiani G, De Michieli L, Di Bella G, Autore C, Perfetto F, Rapezzi C, Sinagra G, Merlo M. Incidence and Risk Factors for Pacemaker Implantation in Light Chain and Transthyretin Cardiac Amyloidosis. Eur J Heart Fail 2022; 24:1227-1236. [PMID: 35509181 DOI: 10.1002/ejhf.2533] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/01/2022] [Accepted: 05/02/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS The incidence and risk factors of pacemaker (PM) implantation in patients with cardiac amyloidosis (CA) are largely unexplored. We sought to characterise the trends in the incidence of permanent PM and to identify baseline predictors of future PM implantation in light chain (AL) and transthyretin (ATTR) CA. METHODS AND RESULTS Consecutive patients with AL and ATTR-CA diagnosed at participating Centres (2017-2020) were included. Clinical data recorded within ±1 month from diagnosis were collected from electronic medical records. The primary study outcome was the need for clinically-indicated PM implantation. Patients with PM (n = 41) and/or permanent defibrillator in situ (n = 13) at CA diagnosis were excluded. The study population consisted of 405 patients: 29.4% AL, 14.6% variant ATTR and 56% wild-type ATTR; 82.5% were males, median age 76 years. During a median follow-up of 33 months (interquartile range 21-46), 36 (8.9%) patients experienced the primary outcome: 10 AL-CA, 2 variant ATTR-CA and 24 wild-type ATTR-CA (p = 0.08 at time-to-event analysis). At multivariable analysis, history of atrial fibrillation (hazard ratio [HR] 3.80, p = 0.002), PR interval (HR 1.013, p = 0.002) and QRS >120 ms (HR 4.7, p = 0.001) on baseline ECG were independently associated with PM implantation. The absence of these 3 factors had a negative predictive value of 92% with an area under the curve of 91.8% at 6 months. CONCLUSION In a large cohort of AL and ATTR-CA patients, 8.9% implanted a PM in the 3 years following diagnosis. History of atrial fibrillation, PR >200 ms and QRS >120 ms predicted future PM implantation.
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Affiliation(s)
- Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.,Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Marco Canepa
- Cardiovascular Unit, Department of Internal Medicine, University of Genova, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giacomo Tini
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Giulia Barbati
- Department of Medical Sciences, Biostatistics Unit, University of Trieste, Trieste, Italy
| | - Guerino Giuseppe Varrà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Cristina Morelli
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Pier Filippo Vianello
- Cardiovascular Unit, Department of Internal Medicine, University of Genova, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Eugenio Sessarego
- Cardiovascular Unit, Department of Internal Medicine, University of Genova, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Domitilla Russo
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Camillo Autore
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Federico Perfetto
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Claudio Rapezzi
- Cardiothoracic Department, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
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18
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Merlo M, Pagura L, Porcari A, Cameli M, Vergaro G, Musumeci B, Biagini E, Canepa M, Crotti L, Imazio M, Forleo C, Cappelli F, Perfetto F, Favale S, Di Bella G, Dore F, Girardi F, Tomasoni D, Pavasini R, Rella V, Palmiero G, Caiazza M, Carella MC, Igoren Guaricci A, Branzi G, Caponetti AG, Saturi G, La Malfa G, Merlo AC, Andreis A, Bruno F, Longo F, Rossi M, Varrà GG, Saro R, Di Ienno L, De Carli G, Giacomin E, Arzilli C, Limongelli G, Autore C, Olivotto I, Badano L, Parati G, Perlini S, Metra M, Michele E, Rapezzi C, Sinagra G. Unmasking the Prevalence of Amyloid Cardiomyopathy in the Real World: Results from Phase 2 of AC-TIVE Study, an Italian Nationwide Survey. Eur J Heart Fail 2022; 24:1377-1386. [PMID: 35417089 DOI: 10.1002/ejhf.2504] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 11/07/2022] Open
Abstract
AIM To investigate the prevalence of amyloid cardiomyopathy (AC) and the diagnostic accuracy of echocardiographic red flags of AC among consecutive adult patients undergoing transthoracic echocardiogram for reason other than AC in 13 Italian institutions. METHODS AND RESULTS This is an Italian prospective multicentric study, involving a clinical and instrumental work-up to assess AC prevalence among patients ≥ 55 years old with an "AC suggestive" echocardiogram (i.e. at least one echocardiographic red flag of AC in hypertrophic, non-dilated left ventricles with preserved ejection fraction). The study was registered at ClinicalTrials.gov (#NCT04738266). 381 patients with an "AC suggestive" echocardiogram were identified among a cohort of 5315 screened subjects. 217 patients completed the investigations. A final diagnosis of AC was made in 62 patients with an estimated prevalence of 29% (95% CI: 23%-35%). Transthyretin-related AC (ATTR-AC) was diagnosed in 51 and light chain related AC (AL-AC) in 11 patients. Either apical sparing or a combination of ≥ 2 other echocardiographic red flags, excluding interatrial septum thickness, provided a diagnostic accuracy > 70%. CONCLUSION In a cohort of consecutive adults with echocardiographic findings suggestive of AC and preserved LVEF, the prevalence of AC (either ATTR or AL) was 29%. Easily available echocardiographic red flags, when combined together, demonstrated good diagnostic accuracy.
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Affiliation(s)
- Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Linda Pagura
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giuseppe Vergaro
- Istituto di Scienze della Vita, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Elena Biagini
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Canepa
- Department of Internal Medicine, University of Genoa, Genoa, Italy.,Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lia Crotti
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Massimo Imazio
- University Cardiology A.O.U. , Città della Salute e della Scienza di Torino, Turin, Italy.,Cardiology, Cardiothoracic Department, University Hospital Santa Maria della Misericordia, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Cinzia Forleo
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | - Francesco Cappelli
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Stefano Favale
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | | | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Francesca Girardi
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Valeria Rella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giuseppe Palmiero
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Martina Caiazza
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Cristina Carella
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | - Andrea Igoren Guaricci
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | - Giovanna Branzi
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Angelo Giuseppe Caponetti
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Saturi
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Alessandro Andreis
- University Cardiology A.O.U. , Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Bruno
- University Cardiology A.O.U. , Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesca Longo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Guerino Giuseppe Varrà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Luca Di Ienno
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Giuseppe De Carli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Elisa Giacomin
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Chiara Arzilli
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Camillo Autore
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Luigi Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stefano Perlini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Emdin Michele
- Istituto di Scienze della Vita, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Rapezzi
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
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19
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Porcari A, Pagura L, Rossi M, Porrazzo M, Dore F, Bussani R, Merlo M, Sinagra G. Light-chain cardiac amyloidosis: a case report of extraordinary sustained pathological response to cyclophosphamide, bortezomib, and dexamethasone combined therapy. Eur Heart J Case Rep 2022; 6:ytac130. [PMID: 35652085 PMCID: PMC9149786 DOI: 10.1093/ehjcr/ytac130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/21/2021] [Accepted: 03/18/2022] [Indexed: 01/15/2023]
Abstract
Abstract
Background
Heart involvement represents the most ominous prognostic factor in light-chain amyloidosis (AL), often foreclosing curative therapies such as high-dose chemotherapy followed by autologous stem cell transplantation (ASCT). Heart transplantation (HTx) may be considered before ASCT in rigorously selected cases of advanced AL cardiac amyloidosis (CA). In ASCT-ineligible patients, chemotherapy with cyclophosphamide, bortezomib, and dexamethasone combined (CyBorD) regimen, even at low-dose, is feasible and effective in obtaining hematological and organ response.
Case Summary
A previously healthy 50-year-old woman presented with severely symptomatic new-onset heart with preserved ejection fraction, significant cardiac hypertrophy, and an ‘apical sparing’ pattern. Bone marrow and abdominal fat biopsy revealed AL amyloidosis due to a smouldering micromolecular λ-type myeloma with severe cardiac involvement, and the patient was judged a good candidate to HTx followed by ASCT. Despite fragile conditions, she tolerated a full course of low-dose combination therapy with bortezomib and was withdrawn from HTx list because of unexpected persistent complete hematologic response and major cardiac improvement. Disease remission was achieved in the long term (>3 years).
Discussion
We report a case of exceptional persistent hematologic and cardiac response after CyBorD therapy in a patient with advanced AL-CA who left the transplantation lists (both HTx and ASCT). In ASCT-ineligible patients, chemotherapy with CyBorD regimen, even at low-dose, can lead to durable remission of the disease with excellent cardiac response.
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Affiliation(s)
- Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Linda Pagura
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Marika Porrazzo
- Department of Hematology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Rossana Bussani
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracic Department, Institute of Pathological Anatomy and Histology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100, Trieste, Italy
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